Utilization Reviewer-Behavioral Health Casual Status Days

The salary range for this position is $37.21 - $52.10 (Hourly Rate)

Placement within the salary range is dependent on several factors such as relevant work experience and internal equity. For positions represented by a labor union, placement within the salary range is guided by the rules outlined in the collective bargaining agreement.

We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section located at jobs.nm.org/benefits to learn more.

Northwestern Medicine is powered by a community of colleagues who are purpose-driven and committed to our mission to deliver world-class care. Here, you'll work alongside some of the best clinical talent in the nation leading the way in medical innovation and breakthrough research with Northwestern University Feinberg School of Medicine.

We recognize where you've been, and we support where you're headed. We celebrate diverse perspectives and experiences, which fuel our commitment to equity and culture of service.

Grow your career with comprehensive training and development opportunities, mentorship programs, educational support and student loan repayment.

Create the life you envision for yourself with flexible work options, a Reimbursable Well-Being Fund and a Total Rewards package that support your physical, mental, emotional, and financial well-being.

Make a difference through volunteer opportunities we offer in local communities and drive inclusive change through our workforce-led resource groups.

From discovery to delivery, come help us shape the future of medicine.

Description

The Utilization Reviewer reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

Responsibilities:

• Responsible for utilization review calls within BHS, including precertification, continued stay review, discharge reviews, and retrospective reviews and appeals.
• Under the direction of the Utilization Review Coordinator, works closely with business office staff, clinical staff, and physicians to advocate for BHS patients with insurance and managed care companies.
• Familiar with and understands DSM diagnoses and ASAM patient placement criteria to communicate patient status to external managed care.
• Communicates insurance input to physicians and clinical staff making discharge plans for patients. Assists clinical staff with assessments as needed, primarily as in a back-up capacity.
• Communicates daily with Utilization Review Coordinator, and as needed with business office and admissions staff to understand admissions and transfers, patient benefit information, and precertification status, including making precertification or notice of admission calls on patients directly to minimize financial risk to patient and facility.
• Understands health care benefit plan provisions and managed care contracting, and communicates benefits and approval status of patients to clinical staff and physicians, and to patients and family members when needed.
• Serves as professional representative of BHS when interacting with reviewers from insurance companies, employers, and managed care plans, and contributes to BHS marketing strategies.
• Communicates and coordinates efforts at appealing unfavorable utilization review decisions, scheduling physician reviews, and monitoring denials and appeals, reporting to Utilization Review Coordinator. EOE Minorities/Women/Disabled/Veterans. VEVRAA Federal Contractor.

Qualifications

Required:

• 2+ years of experience.
• Master's Degree in Social Work or Psychology or BSN with RN License.

Preferred:

• BSN with RN License. CERT BLS, CERT CADC, CERT CSADC, LIC CPC, LIC LCSW, LIC MSW, LIC RN.

Equal Opportunity

Northwestern Medicine is an equal opportunity employer (disability, VETS) and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.

Background Check

Northwestern Medicine conducts a background check that includes criminal history on newly hired team members and, at times, internal transfers. If you are offered a position with us, you will be required to complete an authorization and disclosure form that gives Northwestern Medicine permission to run the background check.  Results are evaluated on a case-by-case basis, and we follow all local, state, and federal laws, including the Illinois Health Care Worker Background Check Act.

Artificial Intelligence Disclosure

Artificial Intelligence (AI) tools may be used in some portions of the candidate review process for this position, however, all employment decisions will be made by a person. 

Benefits

We offer a wide range of benefits that provide employees with tools and resources to improve their physical, emotional, and financial well-being while providing protection for unexpected life events. Please visit our Benefits section to learn more.

Sign-on Bonus Eligibility (if sign-on bonus offered for position): Internal employees and rehires who left Northwestern Medicine within 1 year are not eligible for the sign on bonus. Exception: New graduate internal employees seeking their first licensed clinical position at NM may be eligible depending upon the job family.